2021 Nurses Application Please completely fill-out this application to assist us in reviewing your Nurse Application. Applications cannot be accepted until fully completed. After submitting this application, you will be contacted by the Head Nurse who will notify you regarding the status of your application. If anything regarding the information you provided between now and the start of camp changes, please contact headnurse@campcasey.org so we can have the most up-to-date information. Last minute cancellations cause great hardship for camp leadership and places increased risk management concern for our campers. Have you volunteered for Kiwanis Camp Casey Before?* Yes No Are you associated with another Kiwanis Club?* Yes No What other Kiwanis Club are you associated with?* What organization or person, if any, referred you to Camp Casey? We will be requiring all counselors and volunteers to be fully vaccinated by the time of Camp. Are you or will you be fully vaccinated before camp?* Yes No Depending on the WA state guidelines at the time of camp, will you be comfortable in a camp setting where masks are not mandatory?* Yes No Do you understand that if you begin to experience symptoms that fall under the category of COVID-19, you will need to be tested and obtain a negative test prior to attending camp?* Yes No Contact InfomationName* First Last Date of Birth* MM slash DD slash YYYY Sex* Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone (home)*Phone (work)Phone (cell)Emergency ContactName* First Last Relation Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Alternate PhoneEmail In the event of a medical emergency, what information will an EMT or medical personal attending to your care need to know?Nursing InformationAre you a current nursing student?* Yes No What school are you attending?* How many years of nursing experience do you have?*Nursing License information:* Name as Appears on License License/Credential Number State of Licensure Do you have a secondary Nursing License to list?* Yes No Secondary Nursing License information:* Name as Appears on License License/Credential Number State of Licensure Please list certifications you hold, with their expiration dates:*Do you have personal nurse liability insurance?*Personal nurse liability insurance is required to volunteer at camp, we will assist you in signing up and will reimburse you for the cost. Yes No What company do you hold your policy through?* When does this policy expire?* MM slash DD slash YYYY Employment InformationCurrent Employer:* Position/Area of Nursing:* Start Date:* MM slash DD slash YYYY Duties and Responsibilities:*Do you have any experience working with children or adults with special needs?* Yes No Please write about your experience:*School InformationCollege/University Program:* School Location:* City State / Province / Region Degree Expected to Earn:* Expected Date of Graduation:* MM slash DD slash YYYY Do you have a Nursing Advisor?* Yes No Nursing Advisor Name:* Nursing Advisor PhoneNursing Advisor Email* Time at CampCamp dates are Monday, July 26 through Friday, July 30th. We are switching to a day camp model this year, and volunteers will be required to transport themselves to and from Magnuson Park between the hours of 8am and 5pm.Desired Days to Volunteer*Please check all the days you will volunteer: Monday - July 26th, 2021 Tuesday - July 27th, 2021 Wednesday - July 28th, 2021 Thursday - July 29th, 2021 Friday - July 30th, 2021 Provide any additional comments or information.Please let us know if there is anything else we need to know about the availability of your volunteer time.Dietary Information:* Gluten Intolerant Lactose Intolerant Vegetarian No Food Restrictions Note: The Camp Casey kitchen staff will do their best to accommodate common food allergies. However, given the complexity and procedures for vegan diets the kitchen staff will not be able to provide vegan meals. Sorry for the inconvenience.Camp Casey T-ShirtsPlease provide us with your t-shirt size so we an provide you a t-shirt. Small Medium Large X-Large XX-Large XXX-Large AcknowledgementPlease read and agree to the forms below.Please note you will be asked to read and sign the Camp Casey Counselor Volunteer Release Form before attending Camp.* I acknowledge that I will be asked to review the Release Form prior to attending camp. Agreement will be mandatory prior to attending camp. Please read Camp Casey Counselor Volunteer Code of Conduct.* I have reviewed the Counselor Volunteer Code of Conduct. I know what is expected and agree to the guidelines specified.
